The ACA Five- Years Later

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The ACA Five- Years LaterAn Update on Health
Care Reform

• Al Heuer, PhD, MBA, RRT, RPFT
• Professor Program Director
• Rutgers School of Health Related Professions

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Learning Objectives

• Summarize Key Facts about Our Health Care System
• Review the History Legislative Process of
  Health Care Reform
• Summarize the Some Major Features of the Law.
• Describe the Reality of Its Impact on
• Us as Clinicians and Consumers
• Health Care Organizations
• Review Future Implications
• Furnish Additional Resources

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US Health Care SystemThe Best the Worst

• Strengths
• Strong Investment in Technology Research
• Safety Net for Elderly, Disabled Disadvantaged.
• Weaknesses
• Cost
• In 2010. 47 mil. (16) of Americans were
  Uninsured
• Unequal access to care
• Uneven clinical outcomes
• Health catastrophes are leading cause of U.S.
  bankruptcies.
• Inefficient use of services
• ER as primary care
• Futile CareWe dont know how to say no mas!

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Health Care Systems of Other Countries

• US Health Care cost twice that of other developed
  countries approximates 6th largest national GDP.
  
• Universal Health Care - Canada-national public
  policy provides disincentives for using private
  health insurance.
• National Health Care-England-National Health
  Service founded in 1948. Co-lateral private
  health insurance is allowed.
• Germany spends approx. 10 of its GDP on
  Health Care 5-6 for many European countries

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Initial Attempts at Reform

• FDR wanted national health care to be included in
  the 1935 Social Security Act.
• President Truman attempted to initiate a national
  health care insurance program.
• Was on Jimmy Carters agenda.
• 1993 Hillary Clinton Ultimately unsuccessful,
  largely due to insurance industry opposition.

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Contentious Political Process for This Law

• President Obamas 2010 budget set aside 600
  Billion for Health Care reform.
• July 15, 2009 - Senate Health Committee passes
  its bill.
• August/Sept. - White House loses control of the
  debate.
• November 2009 - Dems introduce new Senate bill,
  including an increased payroll tax on the
  wealthy.
• December 2009 - 25 day debate in the Senate.
• February 2010 - Bi-Partisan summit with Obama.
• March 2010 - To avoid a Senate Republican
  filibuster, House passes the Senate version with
  sidecar of fixes.
• Final Votes House 228-207 Senate 56-43.
• Signed into Law March 23, 2010. (974 pages long)

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Features of the Bill Impact Many Stakeholders
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Initial Features of the Bill - Individuals

• Mandates that all Americans have Health
  Insurance.
• Creates Health Insurance Exchanges for
• Uninsured
• Self-employed
• Subsidies for low-income individuals/families
  (133 to 400 of the poverty level).
• Expands Medicaid coverage.
• Prescription Donut Hole Rebate, Fills some of
  the limits for prescriptions under Medicare.

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Initial Features of the Bill - Individuals (cont.)

• Must cover preventative care, including checks
  ups with no deductible.
• Asthma management
• Smoking cessation
• Coverage for adults with pre-existing conditions.
• Young adults can continue on parents plan until
  age 26.
• Mandated Coverage Penalty of 695/Indiv. in
  2016.

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Features of the Bill - Small Businesses

• Creates similar exchanges for small-medium sized
  businesses.
• Small Business tax Credits 50 of health ins.
  premiums applied as credits for businesses with
  less than 50 employees.
• Companies with 50 or more employees must cover
  95 of full-time employees by 2016.

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Initial Features of the Bill - Insurance Companies

• End of Rescissions-Insurance Cos cant cut
  someone when he/she gets sick.
• Insurance Company Transparency-Must reveal amount
  spent on overhead.
• Higher loss-ratio requirements (now 85) for
  insurance companies to take advantage of tax
  benefits.
• Customer Appeals-Any new plan must implement an
  appeal process for coverage determinations and
  claims.
• 40 tax on insurance companies offering Cadillac
  H.I. Plans.

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Initial Features of the Bill Hospitals
Doctors Practices

• Decreases Medicare coverage but Temporarily
  increased reimbursements for general practice
  physicians/surgeons.
• Medicare payt protections extended to rural
  hospitals.

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Value over VolumePay-For-Performance (P4P)

• ACA Re-Emphasizes Emerging Themes

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What Does Value over Volume Mean to an RT?

• Old Philosophy If a patient stays on a
  ventilator longer or has a stay, thats is good
  for our Job Security!
• New Philosophy - Fewer Vent Days, shorter LOS
  and Happier patients are Rewarded!
• How does this work?

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The Answer The ACAs Value-Based Purchasing
Provision

• Value Based Purchasing Program (VBP)
• Begin to pay hospitals for their actual
  performance
• Requires a portion of Medicare reimbursement to
  be withheld and returned in proportion to how the
  Hospital performs, Initially in 3, Now in 4
  Categories.

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Soooo, VBP Can Reward Clinicians for Contributing
to Better Outcomes!

• Patient weans off ventilator sooner.
• Shorter LOS.
• Better clinical outcome and happier patient means
  higher VBP performance.
• Better VBP performance means more reimbursement
  to the hospital.
• More reimbursement means more for resources,
  including staff, equipment

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ACA created the HRRP, which will reduce
Medicare payment rates for hospitals with higher
than expected readmission rates for specific
conditions.

• Another Form of Pay-for Performance The
  Hospital Readmission Reduction Program (HRRP)

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Conditions Covered Under HRRP

• Initial 2013 Conditions
• Acute Myocardial
• Infarction (AMI)
• Heart Failure
• Pneumonia

• 2015 Expansion
• COPD
• Coronary Bypass Surgery-
• Coronary Angioplasty
• Other Vascular Conditions

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Shhh! Dont Say Frequent Flyer!, HRRP Rewards
Less Frequent Flying and Heres How!

• Patient is admitted but gets enrolled in a
  Re-admission Reduction Protocol
• Patient gets educated about their condition and
  the importance of adhering to their Tx. plan.
• Potential barrier to successful discharge are
  addressed and post discharge follow-up done.
• Patient stays out of the hospital.
• Better HRRP performance means more
  reimbursement to the hospital.
• More reimbursement means more for resources,
  including staff, equipment, etc.

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Changing ReimbursementPay-For-Performance
Payment Reform for Hospitals
Fiscal Year Value Based Purchasing Hospital Readmission Reduction Program Hospital Acquired Conditions Total
2013 1.00 1.00 0 2.00
2014 1.25 2.00 0 3.25
2015 1.50 3.00 1.00 5.50
2016 1.75 3.00 1.00 5.75
2017 2.00 3.00 1.00 6.00
.
Alexander, K.,LHA Legislative regulatory
Update. LA Assn for Healthcare Quality Annual
Education Conference, April 2012
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2013 (Interim) Reimbursement PenaltiesThe Facts

• 2,211 American hospitals received reimbursement
  penalties for high readmission rates
• Together they will forfeit about 280 million in
  Medicare funds over next year
• According to Medicare, 2 out of 3 hospitals
  evaluated failed to meet its new standards for
  preventing 30 day readmissions.
• Hence, more hospitals lost than gained.

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Five years Later-- Public Remains Divided on ACA

• Late June 2015
• Favorable 43
• Unfavorable 40

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Other Realities -- ACA--Five Years Later Health
Ins. Coverage

• 15 million Fewer uninsured individuals since 2010
• But, 35 million Individuals still without
  insurance
• Most gains are from expanded Medicaid expansion
• 12 million More people enrolled in Medicaid since
  2010.

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Health Ins. Coverage - Reality

• 5.8 million people gained coverage in the
  individual market.
• 4.9 million individuals lost employer coverage
  during the same period.
• In other words, for that period in which raw
  data are available, almost 90 of coverage gains
  were in the Medicaid program.

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• Fewer Adults Without Health
• Insurance

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Why do we Care About Medicaid Expansion???

• Positive
• More Americans are Covered!!!
• All adults up to 133 of the FPL will gain
  Medicaid coverage.
• Should promote healthier life styles--Example
• Starting in 2014, Medicaid programs that provide
  prescription drugs must cover tobacco cessation
  medications.
• Those who are low-income and uninsured are more
  likely to use tobacco.
• These enrollees will now have access to six
  cessation counseling sessions a year.
• Negative
• Possible Influx of Insureds with poor health.
• Incentives to Primary Care Physicians to
  Accept Medicaid are running out.
• Cost of expanded Medicaid passed onto tax
  payers?

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ACAPositives Five Years Later - Individuals

• 2.3 million young adults gained coverage from
  2010 through Sept. 2013 by staying on their
  parents' plan.
• 11 million Individuals have insurance through a
  state or federal exchanges.
• 7.7 million Individuals receiving tax subsidies
  for coverage through an exchange.

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ACANegatives Five Years Later - Individuals

• 900,000 Americans individual or
  employer-sponsored health policies were cancelled
  for 2015 because they did not comply with the
  ACA.
• Individual Premiums have increased dramatically.
• 1 in 2 Number of American households eligible for
  a premium subsidy in 2014, paid some money back
  to the government in 2015 because of income
  changes
• 794 Estimated average payment these households
  will owe the government in 2015.

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ACA--Five Years Later Large Corporations

• Group Health Insurance Premiums have Skyrocketed.
• Corporations with 50 Employees must provide
  Health Insurance to 95 of emplyees
• Both of the Above have caused Corporations to
• Be cautious in hiring
• If they do hire, keeping hours below 30/wk.
• Sent more job overseas
• Future uncertainties have curbed other forms of
  corporate spending

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Accountable Care Organizations (ACOs)

• In section 2706 3022 of the ACA
• An ACO is a network of physicians, hospitals, and
  other health providers that collaborate to
  improve care and reduce costs for Medicare
  participants.
• The ACA, created a shared savings program,
  providing incentive payments for improving
  quality and reducing cost.
• A Pioneer ACO--one which has experience in
  coordinating care across settings.

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Accountable Care Organizations (ACOs)- The 2014
Results

• 97 ACOs qualified to share in savings by meeting
  quality and cost benchmarks earned a total
  shared savings of more than 422 mil.
• The results indicate ACOs improve over time 37
  percent of the ACOs that launched in 2012
  generated shared savings
• compared to 27 in 2013
• and 19 in 2014.
• ACOs also improved on quality compared to 2013.
  ACOs that reported in both preceding years showed
  improvement in 27 out of the 33 quality measures
• Clinician-patient communication
• Patient ratings of physicians
• Tobacco Blood Pressure Screening
• EHR use
• 4. The program is still receiving strong
  interest and CMS plans to announce new and
  renewing ACOs.

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ACOs-Why Should you Care?

• May explain increased emphasis on
  interprofessional collaboration between and among
  disciplines/care settings.
• Better coordination better outcomes.
• If your organization is receiving shared savings,
  theres more for staffing, supplies, equip.
  education.
• Can counteract reductions elsewhere, from VBP,
  Short-term Re-admit penalties, and reimburse.
  reductions.

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Meaningful Use the ACA

• Health Care Organizations receive incentives and
  beginning in 2015 penalties for demonstrating
  that they are meaningfully using Electronic
  Health Records (EHRs).
• Meaningful Use was Actually Created by the Health
  Information Technology for Economic Clinical
  Health (HITECH) Act (2009), not the ACA.
• Grants and other incentives are in the ACA to
  promote health information technology
  enhancements.

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EHRs Meaningful Use

• Stage 1 -- 2011-2012
• Electronic capturing of health info.
• Initial reporting of clinical quality measures.
• Using information to Track Clinical Conditions.
• Stage 2 2014
• Increased requirements for e-prescribing and
  incorporating lab results.
• Electronic transmission of patient care summaries
  across multiple settings
• Stage 3 2016
• Improving quality, safety, and efficiency,
  leading to improved health.
• Patient access to self-management tools.

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Meaningful Use Financial Incentives

• Through 2014, 44K-66K per physician in
  financial incentives meeting the criteria.
• Approx. 50-60 of health care facilities fail to
  show that they are using the system in a
  meaningful way
• Penalties for Failing to Demonstrate Meaningful
  Use
• 2015 2016 -- 1-2 reimb. penalty
• 2017-- 3 reimb. penalty
• 2018 -- 4
• 2019 -- 5

1-2 reimb. penalty
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Meaningful Use Why Should Clinicians Care?

• Explains changes to Elec. Health Records (EHR)
  and Computer Physician Order Entry (CPOE) at your
  institution.
• If you organization is receiving Incentives (or
  avoiding penalties), they will have more for
  staffing, equip
• May have a positive Impact of other Measures
  Patient Satisfaction
• Can counteract reductions elsewhere (e.g., VBP,
  S/T Re-admit penalties, etc.

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Meaningful Use Why Else Should Clinicians Care?

• Meaningful Use (Stage 3) promotes Telemedicine
  and Digital Resource Development and other
  similar
• Stage 3 Criteria Outcomes for Improving
  quality, safety, and efficiency, leading to
  improved health outcomes.
• Applications in Respiratory Care
• Virtual Pulmonary Rehabilitation Progs.
• Digital Disease ManagementCOPD, Asthma
• Computerized Educational Resources
• Care Plan Compliance Monitoring
• Smoking Cessation Aids

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Original ProjectionsPaying for the Plan

• Increased Medicare Tax for Singles earning gt
  200K and Couples gt 250K. (Beginning 2013)
• From 1.45 to 2.35 on earned income
• New 3.8 tax on interest, capital gains.
• W-2 reporting of employer H.I. Premium value.
• Will this lead to future taxing of those
  benefits?
• Reductions for Medical Expense Itemization.
• From expenses over 7.5 earned income to over
  10 earned income.
• Medicare Reductions.

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Original Claims -- The ACA Would be A Deficit
Reducer

• Actually President and congress claims it will!
• OMB estimates savings of 138 Billion over 1st 10
  years 1.2 Trillion over next 10 years.
• Reality is Appearing Different.

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Reality--Paying for the Bill

• Reality
• Consumers have experienced sharp, double-digit
  premium increases, combined with breathtaking
  increases in their deductibles.
• The law locks in massive entitlement spending,
  last estimated at 1.7 trillion over the next 10
  years.
• Exchanges are 21.5 less competitive (offer few
  choices)

• Claim
• Health reform would reduce the typical family's
  healthcare costs by 2,500 a year
• The law is a deficit reducer.
• Health Exchanges will increase competition and
  lower premiums

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Other Looming Concerns

• Many provisions didnt activate until 2013-15.
• Little to no mention of Tort Reform, governing
  Med-Mal Lawsuits.
• Some only apply to new insurance companies.
• Originally was to tax cosmetic surgery, but due
  to apparent lobbying efforts, will tax tanning
  shops instead.

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The Future of the ACA?

• U.S. House of Representatives has voted 50 times
  to repeal the entire law.
• Public remains divided on law.
• President Obama works to shore up his legacy.
• Will ACA be a 2016 presidential campaign issue?

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Take Home Notes

• There are many facets to the Health Care Reform
  and the ACA.
• The public remain relatively uninformed.
• Pluses
• Increased the number of those with insurance
• More emphasis on prevention/community care.
• Coverage for pre-existing conditions.
• Big Minuses Cost and No Public Option.
• Changes/amendments are Likely.
• Get informedKeep informed!

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Selected Resources

• http//www.healthreform.gov
• https//www.cms.gov/cciio/resources/Fact-Sheets-an
  d-FAQs/index.html
• http//www.whitehouse.gov/issues/health-care
• http//voices.washingtonpost.com/health-care-refor
  m
• http//www.nytimes.com/2010/02/23/health/policy/23
  health.html
• Longest, BB Health Policymaking in the US ed 5,
  2009